2. Manju Devi, Lalit Arora, Reena Arora

12 Pages·2016·0.54 MB·English

Human Journals
Research Article
June 2016 Vol.:3, Issue:4
© All rights are reserved by Manju Devi et al.
Effectiveness of Sensory Integration Therapy on Gross
Motor Function in Spastic Diplegic Cerebral Palsy Children

Keywords: Cerebral palsy; Spastic diplegic; Gross motor
function; Sensory integration therapy; Conventional therapy

ABSTRACT

Manju Devi1, Lalit Arora2, Reena Arora2 INTRODUCTION: Cerebral palsy (CP), a common, non-
progressive, but not necessarily unchanging neurological disorder of

1. MPT Student 2. Lecturer childhood. Spastic diplegia, the most prevalent form of CP, is
characterized by motor in-coordination, primarily in the lower
University College of Physiotherapy, Baba Farid extremities, that impairs many functional abilities, most notably
ambulation. The evidence supporting the effectiveness of sensory
University of Health Sciences, Faridkot, Punjab, India.
integration therapy on gross motor function in spastic diplegic CP is
scarce. METHODS: 30 Children, both males and females,

diagnosed with diplegic spastic CP were taken from Department of
S ubmission: 2 June 2016
Paediatrics, GGS Medical College and Hospital and OPD,

Accepted: 7 June 2016 University College of Physiotherapy, Faridkot, Punjab. Children
were randomly divided into two groups: Group A (n=15) and Group
P ublished: 25 June 2016 B (n=15) with age 3 to 7 years. All children were evaluated with
Gross Motor Function Measurement (GMFM - 88) scale for rolling,

sitting, crawling, standing and walking dimensions and for spasticity

with Modified Ashworth Scale (MAS) at the beginning and follow
up was done at the end of 2nd and at the end of 4th month one
hour/day with 5 days/week for 4 months. Group A received
conventional physiotherapy and Group B received sensory
integration therapy along with conventional physiotherapy.

RESULT: Gross motor function in Group B improved significantly
www.ijsrm.humanjournals.com (P< 0.05) better than in Group A, after intervention in rolling (P=
0.03), sitting (P=0.0) and crawling (P=0.21) positions; however no
significant difference was seen in standing (P=0.303) and walking

(P=1.00) using independent t- test. MAS scores showed significant
improvements in reducing spasticity with significance p=0.003
(p<0.05) in both groups but the mean of Group B = 0.76 showed
more marked decrease in spasticity than that of Group A =2.00.
CONCLUSION: This study showed the significantly positive effect
of sensory integration therapy on gross motor function in spastic
diplegic CP children.
www.ijsrm.humanjournals.com
INTRODUCTION
“Cerebral palsy describes a group of permanent disorders of the development of movement
and posture, causing activity limitation that is attributed to non-progressive disturbances that
occurred in the developing fatal or infant brain. The motor disorders of cerebral palsy are
often accompanied by disturbances of sensation, perception, cognition, communication,
behaviour, epilepsy and by secondary musculoskeletal problems‟‟ [8].
Cerebral palsy affects males and females in equal numbers [5]. Worldwide; the prevalence of
cerebral palsy is reported to be between 2–2.5 per 1000 live births according to many studies.
The incidence of cerebral palsy in United Kingdom is 2.4 per 1000. It varies between 1.5 and
1.8 per 1000 in the USA. It is 1 per 1000 in France and 1.7 per 1000 live births in Sweden
[1].
Sensory integration refers to the process by which the brain organizes and interprets external
stimuli such as touch, movement, body awareness, sight, sound, and gravity. It occurs in the
brain context and requires balance between the central and peripheral nervous system as well
as between excitatory and inhibitory neurological systems [3, 6].
Problem in sensory integration leads to sensory integration dysfunction (SID) which is
defined as '' the inefficient neurological processing of information received through senses
causing problems with learning, developmental and behaviour‟‟ [10]. Sensory integration
dysfunction is thought to impair the vestibular, proprioception and tactile systems. One
approach to help children with CP achieve their optimal level of functioning is Sensory
Integration Therapy (SIT). Jean Ayres defines the construct of sensory integration as '' the
neurological process that organizes sensation from one's own body and from the environment
and makes it possible to use the body effectively within the environment'' [2]. It appears that
cerebral palsy children share an abnormal degree of sensory processing, whether decreased or
increased. Its aim is to provide the child with graded sensory experiences. It enables the child
to make sense of their world by receiving, registering, modulating, organizing and
interpreting the information that comes to their brains from their senses. SIT helps to
overcome problems experienced by many young children in absorbing and processing
sensory information. Encouraging these abilities ultimately improves balance and steady
movement. So, Sensory integration therapy (SIT) is designed to restore effective neurological
processing and increase the individual ability to integrate sensory information by enhancing
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each of these sensory systems [4]. The aim of this study was to investigate the effectiveness
of the sensory integration therapy on gross motor function in spastic diplegic cerebral palsy
children.
MATERIALS AND METHODS
Design:
Randomization was done by simple random sampling. After baseline assessment, parents of
children drew one of 30 pre-printed cards in opaque sealed envelopes from a box (15 labelled
„group A‟ and 15 labelled „group B‟) and were placed in the intervention in accordance with
the card drawn. The parents of eligible children were duly informed of the rationale and
procedure for the study and were enlightened about the aim of the research in improving
physiotherapy services to children with CP.
Children, therapist and centres:
Out of 40 children referred to the physiotherapy OPD, 30 children with spastic diplegic CP
were selected from a population of children, who had been followed up at University College
of Physiotherapy, Faridkot, Punjab.
Inclusion criteria were: Children of both genders were taken, age groups between 3-7 years,
previously diagnosed as diplegic cerebral palsy. Exclusion criteria were: Children who were
waiting for surgery or has had previous surgery of the foot, leg, or ankle; other conflicting
concurrent treatment, such as plaster casts, Orthoses, BONT-A injection, Baclofen pump or
other treatment effecting neuromuscular transmission at any other point prior to investigation;
prior orthopedic surgery; any of the following diagnosis: Hemophilia, Myasthenia gravis,
Eaton-Lamberts syndrome; children with subluxation or dislocation of hip, fracture of spine
or limbs, severe scoliosis, seizures, mental retardation, fixed contractures and any other
congenital deformity.
Children were divided into a Group A and Group B by randomization. Gross motor function
of children was evaluated according to Gross Motor Function Measure (GMFM-88) scale and
spasticity with Modified Ashworth scale (MAS). The Group B received and participated in
sensory integration treatment plus conventional physiotherapy for 4 months, while the Group
A got conventional physiotherapy alone, which includes routine passive range of motion
exercises, stretching exercises for 4 months performed by physiotherapist on children.
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Assessments at 0th month, at end of 2nd month, and at end of 4th month treatment were
undertaken by one physiotherapist.
INTERVENTION: In this study, the children were treated one hour/day with 5days/week
for 4 months. The Group B underwent sensory integration therapy plus conventional
physiotherapy. In each session, exercises and the following activities were completed by
Group B;
Sensory integration therapy: Visual perception activities: Block design, finding shapes in
pictures, puzzles, matching geometric shapes and letters, numbers, and classification; Body
awareness: Pointing to the body parts, life-size drawing, turning left and right side and
awareness of the body parts through touch; Tactile perception: Feeling various textures,
touching boards and feeling shapes; Visual-motor coordination training: Ocular-pursuit
training, moving ball and pegboard activities [15]. Conventional physiotherapy: Passive
stretching exercises, Passive range of motion exercises.
The Group A underwent the conventional physiotherapy alone. The Independent sample t-test
used for comparison of initial measurements in the two groups revealed no significant
differences in 5 dimensions (p > 0.05). Independent sample t-test used for comparison of
scores between two groups. The intervention mean scores at 0th month, at end of 2nd month
and at end of 4th month for each of the two groups were analysed using a paired-sample t-test,
to determine whether there were any significant differences. Statistical analysis was
performed with SPSS (version 20), with P-values less than 0.05 considered statistically
significant.
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Figure 1. Flow Chart of Treatment Procedure
OUTCOME MEASURES: All assessments were done at 0th month after randomization, at
end of 2nd month, and at end of 4th month treatment by physiotherapist. The Standardized
validated measure of function were used: The GMFM (GMFM-88) is a clinical measure
designed to assess gross motor abilities of children with CP in five dimensions: (1) Lie and
Roll, (2) Sit, (3) Crawl And Kneel, (4) Stand, (5) Walk, Run, and Jump. This measure has
been studied for its reliability and validity [15].
The modified Ashworth scale [12] attempt to measure the severity of hypertonia using
clinical assessment scales. A study was conducted with n = 30, mean age = 59.3 (17.6) years,
patients with central nervous system lesions found excellent inter-rater reliability using MAS
between two experienced raters (Kendall's tau = 0.847, p < 0.001) [13].
DATA ANALYSIS AND RESULTS: Overall 30 children completed the complete duration
of the treatment for 4months. 15 in Group A ( 6 females, 9 males, age range 3-7 years; mean
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age 4.86 years) and 15 in Group B (5 females, 8 males, age range 3-7 years; mean age 5.0
years).
Independent t-test was performed for inter group comparison between Group A and B to
analyse the changes in gross motor function and muscle tone at 0th month to end of 2nd
month, at end of 2nd month to end of 4th month and 0th month to end of 4th month using
GMFM-88 scale and MAS, respectively. An alpha level of p < 0.05 was the level of
significance for the test. ROLLING: The value of GMFM-88 (Rolling) did not show
significant improvement (p>0.05) at end of 2nd month as compared to 0th month. However, at
0th month to end of 4thmonth the scores of rolling in GMFM-88 showed significant
improvement (p<0.05) that is p= 0.003 and t = 3.256 compared to both at 0th month and end
of 2nd month; SITTING: The value of GMFM-88 (Sitting) did not improve significantly
(p>0.05) at end of 2nd month as compared to 0th month. However, at end of 0th month to end
of 4thmonth it showed significant improvement (p<0.05) i.e. p= 0.000 and t = 6.329 compared
to both at 0th month and after 2nd month; CRAWLING: The value of GMFM-88 (Crawling)
showed significant (p<0.05) improvement in GMFM scores i.e. p=0.021 and t=2.452 at end
of 2nd month as compared to 0th month and also showed significant (p<0.05) improvement
in GMFM-88 Score i.e. p= 0.021 and t =2.449 compared to both at 0th month and 2nd month;
STANDING: The value of GMFM-88 did not show significant (p<0.05) improvement in
GMFM-88 score at end of 2nd month and at end of 4th month as compared to 0th month and at
end of 2nd month to end of 4th month; WALKING: The value of GMFM-88 did not show
significant (p>0.05) improvement in GMFM-88 scores i.e. p =1.00 and t = 0.0 at end of 2nd
month and end of 4th month as compared to 0th month and at end of and at end of 4th month.
The independent t-test revealed that in children of Group A and B, gross motor function
significantly improved after intervention in 3 dimensions: rolling, sitting, crawling
(p<0.05).However, no significant improvement in standing and walking dimensions (p>0.05)
(Figure 2).
Paired t-test was performed for intra-group comparison within each Group A and B to
analyse the changes in gross motor function and muscle tone at 0th month to end of 2nd
month, at the end of 2nd month to end of 4th month and 0th month to end of 4th month using
GMFM-88 and MAS, respectively. An alpha level of p < 0.05 was the level of significance
for the test. The paired t-test for the Group A revealed significant differences in GMFM- 88
scores in rolling, sitting ,crawling abilities only ( p=<0.05)) i.e.p= 0.000 at 0th month to the
end of 2nd month and end of 2nd month to the end of 4th month. However, in crawling and
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walking no significant differences were observed (p> 0.05). The paired t-test used for 0th
month, at the end of 2nd month and at the end of 4th month measurements for the Group B
revealed significant differences in GMFM- 88 scores in rolling, sitting, crawling and standing
abilities (P< 0.05) i.e. p = 0.000 , respectively . However, only in walking ability no
significant difference was observed (P> 0.05) i.e. p=0.164 and t= -1.468 .The Paired-sample
t-test revealed that in children of Group B, gross motor function significantly improved after
intervention in 4 dimensions: rolling, sitting, crawling and standing positions.
(p<0.05).However, in Group A gross motor function significantly improved after intervention
only in the 3 dimensions: rolling, sitting and crawling position (p<0.05) (Figure 2).
The Independent t-test revealed that MAS scores showed significant improvements in
reducing spasticity with significance p=0.003 (p<0.05). The paired t-test revealed that mean
of MAS score at 0th month, at the end of 2nd month and at the end of 4th month of Group A
and Group B showed significant difference. But the mean of Group B=0.76 shows more
marked decrease in spasticity than that of Group A =2.00 (Figure 3).
However, according to our results, as initially hypothesized, SIT along with conventional
physiotherapy intervention had a significant positive effect on gross motor function in
children with CP. Therefore from the above statistical analysis, the alternative hypothesis has
been accepted and null hypothesis rejected.

Figure 2. Inter and Intra Group comparison at 0th month, at end of 2nd month and at
end of 4th month scores measurement of GMFM-88 of Group A and Group B ( X- axis
showing dimensions scores, Y -axis showing Mean)
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Figure 3. Comparison at 0th month, at the end of 2nd month and at the end of 4th month
of MAS measurement of Group A and Group B.
DISCUSSION
“Cerebral palsy describes a group of permanent disorders of the development of movement
and posture, causing activity limitation i.e. attributed to non-progressive disturbances that
occurred in the developing fatal or infant brain. The motor disorders of cerebral palsy are
often accompanied by disturbances of sensation, perception, cognition, communication,
behaviour, epilepsy and by secondary musculoskeletal problems” [8]. As a result, children
with CP lack normal muscle tone and less gross motor functions which effects control of
limbs, head, and overall posture [14]. The purpose of the study was to evaluate the
effectiveness of sensory integration therapy on gross motor function in spastic diplegic
cerebral palsy children.
The previous studies and evidences were more on effectiveness of sensory integration therapy
in Autism children. Less research data was available about the effectiveness of sensory
integration therapy in spastic diplegic cerebral palsy children. The present study was done to
evaluate the effectiveness of sensory integration therapy on gross motor function in spastic
cerebral palsy children.
30 Children were randomly divided into two groups: Group A (n=15) and Group B (n=15)
with each group n=15. Group A received conventional physiotherapy and Group B received
sensory integration therapy along with conventional physiotherapy. All children were
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Citation: Manju Devi et al. Ijsrm.Human, 2016; Vol. 3 (4): 23-34.
www.ijsrm.humanjournals.com
evaluated with gross motor function measurement (GMFM - 88) scale for rolling, sitting,
crawling, standing and walking dimensions and for spasticity with Modified Ashworth Scale
before the start of intervention and follow up was done at end of 2nd and end of 4th month
with duration of 5 days per week for 4 months. The data presented in the previous chapter is
discussed according to the objectives, to establish whether the children's gross motor function
and spasticity improved during 4 month period. The data was examined for statistically
significant information. The limitations of study were also reviewed. This study concluded
that sensory integration therapy provides the spastic diplegic cerebral palsy children with
graded sensory experiences. It enables the child to make sense of their world by receiving,
registering, modulating, organizing and interpreting the information that comes to their brains
from their senses. It helps in significant improvement in 3 dimensions such as rolling, sitting,
crawling except in standing, walking dimensions. So, it was concluded from this study that
both conventional physiotherapy and conventional physiotherapy with sensory integration
therapy were effective in improving gross motor functional abilities in children. Children
who had received Sensory integration therapy plus conventional physiotherapy showed more
improvement in gross motor functional abilities and spasticity as compared to those who
received conventional physiotherapy alone. However, statistically it was concluded that
Sensory integration therapy plus conventional physiotherapy is better than alone conventional
physiotherapy. The findings of the study shows that following 4 month of intervention there
is a marked difference in the 0th to end of 4th month. Thus, our study supported the alternate
hypothesis and rejects null hypothesis.
The present study are consistent with other studies which concluded the effect of sensory
integration therapy in spastic CP. Shamsoddini, Alireza et al.,2010 who investigated a study
to determine the comparison between the effect of Neuro- developmental treatment and
sensory integration therapy on gross motor function in children with cerebral palsy. 22
children with spastic CP were randomly divided into two groups, sensory integration therapy
was given to first group and Neurodevelopmental treatment was given to second group.
When two groups were compared, a significant difference was found in lying and rolling
(P=0.003), sitting (0.009), crawling and kneeling (0.02) and standing ability (P=0.04). But no
significant difference in walking, running, and jumping abilities between two groups (0.417).
This result showed that neurodevelopment treatment and sensory integration therapy
improved gross motor function in children with cerebral palsy in four dimensions (rolling,
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sitting, crawling, and kneeling, standing) [9]. This study is relevant with the present study for
the use of sensory integration therapy in spastic diplegic cerebral palsy children.
Other similar studies were also found by May-Benson et.al, 2010 in which twenty-seven
studies were systematically reviewed to identify, evaluate, and synthesize the research
literature on the effectiveness of sensory integration (SI) intervention on the ability of
children with difficulty processing and integrating sensory information to engage in desired
occupations and to apply these findings to occupational therapy practice. Results suggest the
SI approach may result in positive outcomes in Sensory-motor skills and motor planning;
socialization, attention, and behavioural regulation; reading-related skills; participation in
active play; and achievement of individualized goals. Gross motor skills, self-esteem, and
reading gains may be sustained from 3 months to 2 years. This study results are inconsistent
with the results of the present study which showed significant improvement using sensory
integration therapy in spastic diplegic cerebral palsy children [7].
Vargas et al., 1999 did a meta-analysis to determining whether existing studies of treatment
using sensory integration approaches support the efficacy of sensory integration treatments.
Sixteen studies were used to compare sensory integration therapy with no treatment and 16
studies were used to compare sensory integration therapy with alternative treatments. Results
showed a significant difference between the averages sizes of effect of the earlier studies
compared to more recent studies. Earlier studies showed large treatment effects favouring SI
over no-treatment controls. More recent studies did not show overall positive effects. While
general limitations in the methods and statistical analysis of the primary studies were
summarized, there was no description of the characteristics of the individual articles [11].
So, these studies supported that there was a future need to be done to find valid results with
sensory integration therapy in cerebral palsy child.
LIMITATIONS OF THE STUDY:
The number of children was very small for the study. There were only 30 children involved
in present study. Small number of samples inclusion may be affected by external validity of
the study and the results might not be representative of the population. Resources were
limited which have a great deal of impact on the study such as literature relevant to this topic,
data collection time and financial support for conducting the research project.

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